Moral Character Endorsement Form
The Maryland State Board of Occupational Therapy Practice is gathering information to
determine whether the applicant
for licensure to practice occupational therapy in Maryland
can be anticipated to do so ethically. Persons who complete
this form must have observed the applicant's clinical skills, and not be related to the applicant.
Name of Applicant: ______________________________________ Phone: (____)
_______________________
Address:
_____________________________________________________________________________________
City/State/Zip: ______________________________________________________________________________
| License Type You are Applying For: |
Occupational Therapist |
( ) |
|
Occupational Therapy Assistant |
( ) |
|
Temporary Occupational Therapist |
( ) |
|
Temporary Occupational Therapy Assistant |
( ) |
| To the best of your knowledge, has the applicant: |
|
| 1. |
Provided appropriate services to clients without
discrimination based on age, race, creed, national
origin, sex, sexual orientation, handicap, or religious affiliation? |
1. ( ) Yes |
( ) No |
| 2. |
Shown respect for clients' rights, including the right to refuse
treatment?
|
2. ( ) Yes |
( ) No |
| 3. |
Avoided cruel, inhumane, or degrading practices in the treatment of
clients?
|
3. ( ) Yes |
( ) No |
| 4. |
Provided the highest quality services to clients?
|
4. ( ) Yes |
( ) No |
| 5. |
Placed the needs of the client above personal gains,
financial or otherwise? |
5. ( ) Yes |
( ) No |
| 6. |
Appropriately represented his or her skills?
|
6. ( ) Yes |
( ) No |
| 7. |
Continued with any procedure which appeared to be harmful to the client? |
7. ( ) Yes |
( ) No |
| 8. |
Practiced occupational therapy without an appropriate license?
|
8. ( ) Yes |
( ) No |
| 9. |
Used any form of communication containing a false, fraudulent,
misleading, deceptive
claim? |
9. ( ) Yes |
( ) No |
| 10. |
Failed to comply with any laws dealing with the practice of occupational
therapy? |
10. ( ) Yes |
( ) No |
| 11. |
How long have you been acquainted with the applicant?
|
11. ________ |
Years |
12. Describe the manner in which you are familiar with the applicant's
clinical skills.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
13. I attest that the information provided is true to the best of my
knowledge:
____________________________________
___________________________________________
Name
Signature
_________________________________________
___________________________________________
Job Title
Date
_________________________________________
___________________________________________
Address
City/State/Zip
_________________________________________
____________________________________________
Home Phone Number
Work Phone Number
If this form has been completed by someone who has not observed the
applicant's clinical skills, it will be rejected
and may delay the processing of
this application.
DO NOT FORWARD THE COMPLETED FORM TO THE APPLICANT.
The completed original form must be returned directly to:
MD Board of Occupational Therapy
Spring Grove Hospital Center
TDD FOR DISABLED
55 Wade Avenue
MARYLAND RELAY SERVICE
Baltimore, MD 21228
1-800-735-2258
(Rev. 6/15/01)
FAX COPIES OF THIS FORM WILL NOT BE ACCEPTED.
[ Home ] [ Checklist ] [ Duplicate License ] [ Official ] [ Moral Character Form ] [ Temporary ] [ Reinstatement ] [ Renewal ] [ Instructions ] [ State Verifications ]
|